Thursday, December 13, 2012

OPERATE OR NOT OPERATE the GALLBLADDER? The EIS ISSUE

OPERATE OR NOT OPERATE the GALLBLADDER? The EIS ISSUE

When working and silent, the bleb is where is stored bile, a greenish liquid, bitter and slimy, secreted by the liver and which, through its own system of channels, led to the duodenum, participating so important digestion. But, sometimes, one dysfunction, a change occurs in the production of bile, the formation of precipitate crystals, which, little by little increasing in size and will give rise to so-called gallstones. Most people who have no symptoms calculations. Although laparoscopic surgery is widespread, it is only indicated in certain cases. What is the evolution of asymptomatic gallstones? The frequency of symptoms and complications of gallstones discovered by chance is relatively small. In general, those with gallstones never present symptoms or complications from calculations asymptomatic gallstones. Still, many researchers have been trying to establish which patients could present problems bile throughout his life. To our knowledge, there seems no relationship between symptoms and age, sex and number of calculations. So far, there is consensus that the evolution of the calculations that have no symptoms is benign and requires no intervention. What is the evolution of symptomatic gallstones? Moreover, since the calculations cause typical symptoms of biliary disease, risk of persistence of the problems is relatively high. Moreover, most of the complications of biliary calculus disease is preceded by an attack of biliary colic. Therefore, since the patient had biliary colic, the trend is that these episodes recur to culminate in some complication, if nothing is done. As the biliary colic manifests? The main complaint of patients with symptoms is biliary colic. Most clinicians agree that biliary colic - the most characteristic symptom of calculating gallbladder - is not an appropriate name because the pain is not the cramping. Rather, it is a very intense and continuous pain in the upper abdomen, and during which alternate periods of worsening and improvement. This pain lasts from 15 minutes to hours and is commonly accompanied by nausea and vomiting. Frequently evolves without precipitating factors. The interval between episodes can vary from days to months or even years, and rarely, daily symptoms can be attributed to gallstones. The biliary colic should be distinguished from nonspecific symptoms that characterize functional dyspepsia. Gas, heartburn, abdominal discomfort, intolerance to fatty foods are frequent complaints in clinics. However, both occurring in patients with stones as in patients without gallstones. This differentiation is critical to successful treatment, since this is only indicated for biliary colic. In the episode of biliary colic without complications are not detected changes in laboratory tests. The main test to confirm the diagnosis of gall calculation is the abdominal ultrasound. What are the main complications of gallstones? When the framework persists for more than six hours, the suspicion of acute cholecystitis should be rejected. Most patients with acute cholecystitis have previous episodes of biliary colic. The pain of acute cholecystitis is more prolonged, can be located more precisely on the right side of the upper abdomen and is associated with fever. In the presence of acute cholecystitis, a gallbladder wall is thickened on ultrasound examination. Once the vesicle becomes inflamed, signs of infection and elevated liver enzymes appear in blood tests. In some patients, the calculations can escape from the vesicle. If they are small, they can pass through the bile ducts to the gut, leaving faeces. If they are slightly larger, can become lodged in the bile ducts, causing complications such as jaundice, cholangitis or pancreatitis. The obstruction of the passage of bile results in jaundice (yellowing of skin and whites of the eyes) and itching. Calculations in the main bile duct are frequently associated with infection, resulting in the serious situation of acute cholangitis, which is characterized by biliary colic, jaundice, fever and chills, requiring urgent treatment. Acute pancreatitis (inflammation of the pancreas) can also be caused by passing through the channel biliary calculi. Some experts recommend the removal of the gallbladder with calcified walls (also called vesicle porcelain) the risk of developing bladder cancer. Although calculations (larger than 3 cm) may be associated with bladder cancer, withdrawal prophylaxis is still controversial. What is the best treatment option? There is consensus that the calculations should not be treated asymptomatic. Only calculations with symptomatic or calcified gallbladder complications and should be treated. Options include surgery (cholecystectomy), dissolution or fragmentation of the calculations. Surgery is the only definitive treatment. It is a simple and safe surgery, and indicated for most patients with stones. Currently, laparoscopic cholecystectomy facilitated the procedure with a shorter hospital stay, fewer complications and quicker return the patient to their routine. It is for this reason that cholecystectomy has become choice for most patients with gall stones. However, in about 5% of cases and the presence of complications, the conventional cholecystectomy may be a better option. The non-surgical treatment is reserved for patients who do not want to undergo surgery or have a very high surgical risk. Importantly, both the dissolution as the fragmentation of the calculations are not definitive procedures. As the bladder is not removed, the calculations can, over time reappear. The calculations present in the bile ducts can be removed through an endoscopic examination, called endoscopic retrograde cholangiopancreatography (ERCP). This test may be performed before, during or after cholecystectomy. Symptoms may persist after cholecystectomy? The persistence of symptoms after cholecystectomy should be observed and discussed with patients before subjecting them to surgery. Many physicians tend to indicate the occurrence of cholecystectomy versus nonspecific symptoms such as intolerance to fatty foods, gas, belching, heartburn, nausea. Although some patients may improve such symptoms after surgery, several studies have shown that these may be present in the presence or absence of gallstones, and therefore are not disease specific bile. Perform a cholecystectomy just to see if these symptoms improve is not recommended. Furthermore, the cholecystectomy procedure is not innocuous and may cause other symptoms such as diarrhea post-cholecystectomy. For the broad spectrum of clinical presentations, the possibility of improvement in some patients and ease offered by laparoscopic cholecystectomy, surgery may even occasionally be required in patients with such symptoms, provided they are intolerable have negative investigation for other causes, or the subject has been previously discussed with the patient and the same has accepted the possibility that the symptoms are not relieved by surgery.